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Massachusetts Health Care Proxy Form 1

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Massachusetts Health Care Proxy Form 1
Massachusetts Health Care Proxy Form 1
NOTICE: The following form is protected by federal copyright law and may be photocopied or reproduced only by the end user for
his or her personal use. Health care organizations, institutions, professionals, and others can purchase the form in quantity from
Massachusetts Health Decisions, the non-profit publisher of the form and educational materials related to the Massachusetts Health
Care Proxy. The form is available in English and nine other languages. A complete information packet including two copies of the
form, a basic brochure, and a 16-page "User's Guide" in question-and-answer format is available for $6 postpaid. Please contact:
Massachusetts Health Decisions, PO Box 417, Sharon, MA 02067.
Information, Instructions, and Form
What does the Health Care Proxy Law allow
The Health Care Proxy is a simple legal document that allows you to name someone you know and trust to
make health care decisions for you if, for any reason and at any time, you become unable to make or commu-
nicate those decisions. It is an important document, however, because it concerns not only the choices you
make about your health care, but also the relationships you have with your physician, family, and others who
may be involved with your care. Read this and follow the instructions to ensure that your wishes are honored.
Under the Health Care Proxy Law (Massachusetts General Laws, Chapter 201D), any competent adult 18
years of age or over may use this form to appoint a Health Care Agent. You (known as the "Principal") can
appoint any adult EXCEPT the administrator, operator, or employee of a health care facility such as a hospital
or nursing home where you are a patient or resident UNLESS that person is also related to you by blood, mar-
riage, or adoption.
What can my Agent do
Your Agent will make decisions about your health care only when you are, for some reason, unable to do that
yourself. This means that your Agent can act for you if you are temporarily unconscious, in a coma, or have
some other condition in which you cannot make or communicate health care decisions. Your Agent cannot act
for you until your doctor determines, in writing, that you lack the ability to make health care decisions. Your
doctor will tell you of this if there is any sign that you would understand it.
Acting with your authority, your Agent can make any health care decision that you could, if you were able. If
you give your Agent full authority to act for you, he or she can consent to or refuse any medical treatment,
including treatment that could keep you alive.
Your Agent will make decisions for you only after talking with your doctor or health care provider, and after
fully considering all the options regarding diagnosis, prognosis, and treatment of your illness or condition.
Your Agent has the legal right to get any information, including confidential medical information, necessary to
make informed decisions for you.
Your Agent will make health care decisions for you according to your wishes or according to his/her assess-
ment of your wishes, including your religious or moral beliefs. You may wish to talk first with your doctor,
religious advisor, or other people before giving instructions to your Agent. It is very important that you talk
with your Agent so that he or she knows what is important to you. If your Agent does not know what your
wishes would be in a particular situation, your Agent will decide based on what he or she thinks would be in
your best interests. After your doctor has determined that you lack the ability to make health care decisions, if
you still object to any decision made by your Agent, your own decisions will be honored unless a Court deter-
mines that you lack capacity to make health care decisions.
© Massachusetts Health Decisions 1999
Licensed for use by the Massachusetts Medical Society
Massachusetts Health Care Proxy Form 1